Day: March 30, 2024

Overview Tonsillitis refers to the acute inflammation of the palatine tonsils secondary to infection. Acute tonsilitis is very common, especially in children. It is most frequently viral and associated with an upper respiratory tract infection (URTI). It may also be caused by bacteria (e.g. Group A Streptococci). Management typically involves reassurance, fluids and analgaesia. Where a bacterial cause is suspected, antibiotics +/- steroids are given. The most common complication of acute tonsillitis is a peritonsillar abscess (see Quinsy). Recurrent severe tonsillitis results in considerable morbidity and time lost from school or work. Clinical features Clinical examination typically demonstrates enlarged and erythematous tonsils. Exudate is more uncommon and typically suggests

Introduction Thyroid cancer accounts for around 1% of new malignancies in the UK each year. Thyroid cancer refers to a group of malignant conditions affecting the thyroid gland. They most commonly present with a thyroid lump and are diagnosed following triple assessment. Surgical resection (thyroidectomy and hemithyroidectomy) is the mainstay of treatment. Prognosis is related to the type, stage and age at diagnosis. This note will focus primarily on the diagnosis and management of papillary and follicular thyroid cancer (together often referred to as differentiated thyroid cancers). Epidemiology There are approximately 3,900 diagnoses of thyroid cancer in the UK each year. It is

Overview The thyroid is located in the mid-line of the neck, anterior to the trachea and inferior to the larynx. It is found within the pre-tracheal fascia, one of the fascial compartments of the neck. It is a thin fascia in the anterior part of the neck and is composed of two parts: Muscular part: contains the infrahyoid muscles Visceral part: contains the thyroid, trachea and oesophagus The thyroid gland is comprised of two lateral lobes connected by a central isthmus. It is surrounded by a fibrous capsule and located at the level of vertebrae C5-T1. The pyramidal lobe, an embryological

Overview Ramsay hunt syndrome refers to the reactivation of herpes zoster in the geniculate ganglion. The terminology can be confusing. Technically it is Ramsay Hunt syndrome type II (type I is a form of cerebellar degeneration). It can also be referred to as herpes zoster oticus. It is characterised by a facial nerve palsy associated with a vesicular rash affecting the ipsilateral ear, hard palate and anterior two-thirds of the tongue. Treatment is with antivirals, steroids (+/- gastro-protection) and appropriate eye care.   Facial nerve The facial nerve is divided into five branches, which collectively control the muscles of facial expression. The

Overview Quinsy, also termed peritonsillar abscess, is a collection of pus in the peritonsillar space. There are two types of infection that affect the peritonsillar regions: Peritonsillar cellulitis: refers to infection of the peritonsillar tissue in the absence of a discrete collection of pus (abscess). Peritonsillar abscess (quinsy): refers to a discrete collection of pus in the peritonsillar region. Quinsy occurs most commonly as a complication of bacterial tonsillitis. Unlike simple tonsillitis, it mandates surgical intervention to drain the collection. Group A beta-haemolytic streptococcus and haemophilus influenzae are commonly implicated. Severe complications are rare but can include sepsis, the spread of the infection through the deep

Overview A pharyngeal pouch, also known as Zenker’s diverticulum, is a sac-like out-pouching that occurs within the hypopharynx. A Zenker diverticulum (ZD), more commonly known as a pharyngeal pouch, is a herniation of the posterior pharyngeal wall that occurs at an area of weakness within the inferior pharyngeal constrictor. It typically occurs in older adults and can lead to symptoms of dysphagia, regurgitation, and more seriously, aspiration pneumonia. Pharyngeal pouch seen at endoscopy with a transparent distal attachment. Evidence of previous endoscopic stapling Epidemiology A pharyngeal pouch is rare before the age of 40. A pharyngeal pouch is a relatively rare condition

Introduction Ménière’s disease is a disorder of the inner ear that manifests itself with attacks of vertigo, tinnitus and hearing loss. The majority of cases of Ménière’s disease are idiopathic but the condition is thought to be related to abnormal production and absorption of endolymph (the fluid that fills portions of the labyrinthine system). Where an underlying cause is identified it is referred to as Ménière’s syndrome. The disease is characterised by episodes of vertigo, tinnitus and fluctuating hearing loss. As the condition develops, symptoms, in particular tinnitus and hearing loss, may become permanent and progressively worse. Management involves supportive care during acute

Overview Malignant otitis externa is a serious condition where infection spreads from the external auditory canal to the skull base. It most commonly affects the elderly, diabetic or immunocompromised. Pseudomonas aeruginosa is by far the most common causative pathogen. Treatment is primarily with intravenous antibiotics and supportive care. Risk factors The majority of cases of malignant otitis externa are associated with diabetes or glucose intolerance. Diabetes Old age Immunocompromise (e.g. HIV) Aetiology Pseudomonas aeruginosa is the most common cause of malignant otitis externa. Pseudomonas aeruginosa is a gram-negative rod. It normally causes infections in patients with deficient immune systems or poor glycemic control. Less commonly other pathogens are

Introduction Epistaxis refers to bleeding from the blood vessels within the nasal mucosa. Nosebleeds are common. The vast majority resolve spontaneously or with basic first aid. However, it remains a relatively common cause of presentation to A&E departments, with up to 6% of the UK population seeking medical attention due to epistaxis at some point in time. On occasion, epistaxis requires intervention (e.g. nasal cautery or nasal packing) typically performed by an A&E or ENT doctor. In certain settings (discussed in more detail below), epistaxis should trigger an outpatient referral to ENT to exclude an underlying causative lesion (e.g. malignancy). Aetiology

Overview Chronic rhinosinusitis refers to inflammation of the nasal cavities and paranasal sinuses lasting > 12 weeks. Chronic rhinosinusitis is broadly defined as inflammation of the nasal cavities and paranasal sinuses that lasts for longer than 12 weeks. However, it is actually a very heterogenous condition that is difficult to fully define and may be part of a wider systemic illness (e.g. granulomatosis with polyangiitis). There are various subtypes of chronic rhinosinusitis although the cardinal features remain the same, which include nasal congestion, mucopurulent nasal discharge, and facial pain or pressure. Treatment aims to reduce symptom burden and improve quality of

Overview Benign paroxysmal positional vertigo (BPPV) is an inner ear disorder characterised by episodes of positional vertigo. BPPV is the most commonly encountered cause of vertigo seen in clinical practice. It is caused by otoconia (loose debris composed of calcium carbonate) within the semilunar canals of the inner ear. Attacks are triggered by head movements that result in movement of the otoconia, abnormal motion of endolymph and the feeling of vertigo. A careful history and examination are required to exclude other causes of vertigo. ‘Manoeuvres’ (explained in detail below) are used in both the diagnosis and treatment of BPPV. The Dix-Hallpike

Overview Allergic rhinitis is a common condition secondary to IgE-mediated inflammation of the nasal mucosa. Allergic rhinitis is a common condition characterised by sneezing, runny nose (i.e. rhinorrhoea), nasal obstruction and itching. It is more colloquially known as ‘Hayfever’. These symptoms are brought about by IgE-mediated inflammation secondary to antigens known as ‘allergens’ that can include grass, tree pollen, or house dust mites among many others. The diagnosis of allergic rhinitis is clinical and management aims to dampen the immune response to allergens principally with anti-histamines and intranasal glucocorticoids. It may be a very disabling condition and is commonly associated with

Overview Acute rhinosinusitis refers to acute inflammation of the nose and paranasal sinuses. Acute rhinosinusitis is a common condition that is usually caused by a viral pathogen. It leads to typical features of nasal congestion, nasal discharge, and facial pressure/pain that is worse on bending forward. These symptoms completely resolve within 4 weeks. Similar to an upper respiratory tract infection, symptoms will improve without intervention and antibiotics are rarely required. Terminology Rhinosinusitis is a better term than simply ‘sinusitis’ because inflammation of the nasal cavities almost always accompanies sinusitis. Sinusitis versus rhinosinusitis Sinusitis: symptomatic inflammation of the paranasal sinuses Rhinosinusitis: symptomatic inflammation

Overview Acute otitis media (AOM) refers to inflammation of the middle ear with effusion and clinical features of a middle ear infection. Normally AOM is a self-limiting condition, commonly occurring in children, though adults can also be affected. In general symptoms settle after 3 days, but can remain for a week. Bacteria or viruses are normally implicated – differentiating the two is challenging. The majority of cases do not require antibiotic therapy and will settle with time. Though rare, serious complications such as mastoiditis, meningitis, intracranial abscess, sinus thrombosis or facial nerve paralysis may occur. AOM may become persistent or recurrent. NICE

Overview Otitis externa refers to inflammation of the external auditory canal. Though the inflammation can have many causes (e.g. allergic, dermatologic), infection, in particular by bacteria, is the most common cause. It may be categorised (definition from NICE CKS) as: Acute: lasts 3 weeks or less Chronic: lasts 3 months or longer Malignant otitis externa (MOE) is a rare life-threatening condition where the infection spreads to the surrounding bone, it is covered here. Epidemiology Up to 10% of people will experience acute otitis externa in their lifetime. Though otitis externa (both acute and chronic) can occur at any age, it is more common in children and

Overview An acoustic neuroma is a benign Schwann-cell derived tumour, which commonly arises from the eight cranial nerve. An acoustic neuroma, also known as a vestibular schwannoma, is a benign intracranial tumour that is derived from Schwann cells that are one of the major supporting nerve cells in the peripheral nervous system. It is typically a slow growing tumour that arises from the eighth cranial nerve supplying the inner ear. This cranial nerve, also known as the vestibulocochlear nerve, has important functions in both hearing and balance. An acoustic neuroma is typically unilateral and leads to unilateral sensorineural hearing loss (bilateral